220 Burnham Street ● South Windsor, CT 06074
Vox 888-255-7293 ● Fax 860-289-0055
Page 1 of 2
Updated 8/7/2012
TENNESSEE BLUE CROSS BLUE SHIELD
DENTAL ELECTRONIC CLAIMS ENROLLMENT REGISTRATION
PAYER ID NUMBER CBTN1
SPECIAL NOTES If a provider does not have a Tennessee BCBS provider number the provider must first submit a paper claim to have one assigned.
ELECTRONIC
REGISTRATIONS
Agreements Required
Change Healthcare Provider Enrollment Form
Please complete all requested information.
Electronic Billing Request
Please complete all requested information.
SEND REGISTRATION FORMS TO
Change Healthcare
220 Burnham Street
South Windsor, CT 06074
Attn: Provider Enrollment
Or
Fax to: 860-289-0055
ENROLLMENT CONFIRMATION
Change Healthcare will notify the provider or their PMS vendor,
as defined by the PMS vendor, when registration is complete.
CHANGING ELECTRONIC
BILLING AGENTS
If the Provider currently submits claims through another Billing
Agent other than Change Healthcare Dental each Provider
must re-enroll following the procedures listed above.
CONTACT PHONE NUMBERS 800-924-7141 Tennessee BCBS Provider Enrollment
Change Healthcare Dental 888-255-7293
220 Burnham Street ● South Windsor, CT 06074
Vox 888-255-7293 ● Fax 860-289-0055
Page 2 of 2
Updated 8/7/2012
PROVIDER ENROLLMENT FORM
Insurance Carrier: Tennessee BCBS- payer IDs CBTN1
Print/Type the following:
Provider/Organization Name: ______________________________________________
Tax Identification or Social Security Number: _________________________________ (Number that will be used to submit electronic claims)
Software Vendor: _______________________________________________________
Group Legacy Number as assigned by the payer:________________________________ (if applicable)
Group Type 2 NPI: ______________________________________________________ (if applicable)
Rendering Provider Information Name Legacy Number Required for all providers NPI – Type 1
_____________________ _____________________ _______________________
_____________________ _____________________ _______________________
_____________________ _____________________ _______________________
_____________________ _____________________ _______________________
Address: _______________________________________________________
City, State, Zip Code: _____________________________________________
Office Contact Name: _____________________________________________
Telephone Number: __________________ Fax Number: ________________
Date: _____________________________